Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A Complication of Femoral Access?

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma:  A Complication of Femoral Access?

 

Raza Askari, MD; Rami N Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI; Dwight A Dishmon, MD, FACC

Perm J 2017;21:16-111 [Full Citation]

https://doi.org/10.7812/TPP/16-111
E-pub: 05/22/2017

Case Presentation

A 69-year-old man with known ischemic cardiomyopathy presented to our Emergency Department with chest pain. He underwent cardiac catheterization via right femoral approach with placement of a drug-eluting stent to his mid left anterior descending artery, and dual antiplatelet therapy with aspirin and clopidogrel was started. Postintervention, the arteriotomy site was sealed using a Mynx (CardinalHealth Inc, Dublin, OH) vascular closure device. No immediate postprocedure complications were noted. Overnight, the patient developed hypotension with penile swelling along with a progressively enlarging scrotal hematoma (Figure 1). No access site swelling or hematoma was evident. A computed tomography scan of the abdomen and pelvis showed soft tissue extending from the pelvis into the scrotum (Figure 2). The patient’s baseline
hemoglobin level before the procedure was 10.5 g/dL, and hematocrit was 32.2%. At the time the swelling was noted, the patient’s hemoglobin had dropped to 7.5 g/dL, and hematocrit was down to 23.3%. He required transfusion of 2 units of packed red blood cells.

The next morning, because of a continued drop in hemoglobin and worsening scrotal swelling, the patient was taken urgently to the catheterization laboratory for right femoral angiography via left femoral approach. The femoral angiogram showed continued spurting of blood from the right common femoral artery access site (Figure 3), probably because of posterior wall puncture during cardiac catheterization. Percutaneous balloon angioplasty was performed using an 8 mm x 40 mm compliant balloon with prolonged inflation (more than 5 minutes) to tamponade the site of the posterior ooze. A subsequent angiogram showed no evidence of bleeding from the common femoral artery (Figure 4). An orthogonal-view angiogram was repeated a few minutes later with similar results.

During the next day, the patient’s hemodynamic and hematologic parameters stabilized. There was gradual reduction in the scrotal swelling until complete resolution was confirmed at follow-up 2 weeks later.

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma:  A Complication of Femoral Access?

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma:  A Complication of Femoral Access?

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma:  A Complication of Femoral Access?

Image Diagnosis: Rapidly Enlarging Scrotal Hematoma:  A Complication of Femoral Access?

Discussion

Access site bleeding is an important complication of femoral access during cardiac catheterization. Causes of access site bleeding include multiple sticks, back wall stick, failure of the closure device, or residual bleeding from the initial site.1,2 The most dreaded manifestation of femoral access site bleeding is retroperitoneal hemorrhage presenting as hypotension, back/flank pain, and sequelae of acute blood loss anemia without any overt signs of bleeding. This manifestation can prolong hospital stay and in rare instances can be fatal. Access site bleeding for femoral access occurs in 0.82% of cases after percutaneous coronary intervention.1 Retroperitoneal bleeding is the most catastrophic manifestation of access site bleeding, occurring in 0.29% of cases.3 A scrotal hematoma occurs when the stick is at or very close to the inguinal ligament, with blood tracking along the spermatic cord into the scrotum. To our knowledge, only a handful of cases of development of scrotal hematoma after femoral artery access have been reported in the literature.4,5 The incidence of bleeding complications has not been shown to be different whether a closure device is used or not.3

Diagnosis of retroperitoneal bleeding is made with abdominopelvic computed tomography.6 Ultrasound or computed tomography can provide the diagnosis for scrotal hematoma.6 Treatment of scrotal hematoma has ranged from conservative measures, including scrotal elevation and resuscitation with IV crystalloids or blood products, to open surgical options.4 Ultrasound-guided compression7 and ultrasound-guided thrombin injection8 are noninvasive measures that are effective for femoral artery pseudoaneurysms, but these measures are unlikely to be effective for unrestrained obvious bleeding. Endovascular balloon tamponade is a minimally invasive option that is frequently successful9 and offers the option to use covered stents in case of failure.6

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Askari R, Khouzam RN, Dishmon DA. Image diagnosis: Rapidly enlarging scrotal hematoma: A complication of femoral access? Perm J 2017;21:16-111. DOI: https://doi.org/10.7812/TPP/16-111.

References
1.    Marso SP, Amin AP, House JA, et al; National Cardiovascular Data Registry. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA 2010 Jun 2;303(21):2156-64. DOI: https://doi.org/10.1001/jama.2010.708.
    2.    Roger VL, Go AS, Lloyd-Jones DM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2011 update: A report from the American Heart Association. Circulation 2011 Feb 1;123(4):e18-e209. DOI: https://doi.org/10.1161/CIR.0b013e3182009701.
    3.    Tavris DR, Wang Y, Jacobs S, et al. Bleeding and vascular complications at the femoral access site following percutaneous coronary intervention (PCI): An evaluation of hemostasis strategies. J Invasive Cardiol 2012 Jul;24(7):328-34.
    4.    Thomas AA, Hedgepeth R, Sarac TP, Vasavada SP. Massive scrotal hematoma following transfemoral cardiac catheterization. Can J Urol 2008 Apr;15(2):4020-3.
    5.    Borden TA, Rosen RT, Schwarz GR. Massive scrotal hematoma developing after transfemoral cardiac catheterization. Am Surg 1974 Mar;40(3):193-4.
    6.    Sambol EB, McKinsey JF. Local complications: Endovascular. In: Cronenwett JL, Johnston KW, editors. Rutherford’s vascular surgery. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p 704-22.
    7.    Coley BD, Roberts AC, Fellmeth BD, Valji K, Bookstein JJ, Hye RJ. Postangiographic femoral artery pseudoaneurysms: Further experience with US-guided compression repair. Radiology 1995 Feb;194(2):307-11. DOI: https://doi.org/10.1148/radiology.194.2.7824703.
    8.    Vázquez V, Reus M, Piñero A, et al. Human thrombin for treatment of pseudoaneurysms: Comparison of bovine and human thrombin sonogram-guided injection. AJR Am J Roentgenol 2005 May;184(5):1665-71. DOI: https://doi.org/10.2214/ajr.184.5.01841665.
    9.    Akkus NI, Beedupalli J, Varma J. Retroperitoneal hematoma: An unexpected complication during intervention on an occluded superficial femoral artery via a retrograde popliteal artery approach. Rev Port Cardiol 2013 Jul-Aug;32(7-8):623-7. DOI: https://doi.org/10.1016/j.repce.2013.10.005.

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